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General Data:

Name: R.A.
Age/Sex: 27/F
Nationality: Filipino
Civil Status: Single
Religion: Roman Catholic
Educational attainment: Elementary graduate
Occupation: Housekeeper
Address: Baybay, Lucod, Banganga, Davao Oriental
Date Admitted: May 9, 2015
Date Interviewed: May 9, 2015
Chief Complaint: Change in Behavior
Patients words: Wala ko kabalo nganu naa ko diri. Mag-outing daw mi inig
makagawas, mao nagsugot ko magpa-admit.
Companions words: Naglahi iyang batasan
Premorbid Personality:
Patient is a silent and shy type of person. She had a good relationship with her
family. She was a loving wife and caring mother to her 3 children. She had few friends at
home.
History of Present Illness:
Three weeks PTA, the patient delivered a live term baby boy via normal
spontaneous vaginal delivery in a local tertiary hospital. There were no noted
complications or any postnatal illnesses.
Eight days PTA, the patient developed an undocumented intermittent high grade
fever. She self-medicated with Paracetamol 500 mg/tablet 1 tablet as necessary which
provided temporary relief. No further consultation was done.

Four days PTA, the patient had onset of 4 episodes of nonbilous,


nonbloodstreaked and nonprojectile vomiting. No medications were taken and no
consultation done.
Three days PTA, the patient began to display disorganized behavior and speech.
The watcher noted that magsige na siyag yawyaw and talks to herself. She claimed that
God is talking to her telling Magbinut-an daw ko. Moreover, she claimed that she was
gisugo sa Ginoo. When asked, she seems to give irrelevant answers. Patient was also
noted to have poor appetite, mixed insomnia and poor personal hygiene.
Due to persistence of above condition, the patient was brought in a lying-in clinic
and referred to a local hospital in Mati. Patient was admitted with an unrecalled
diagnosis.
1 day PTA, the patient was referred to SPMC. Laboratory work ups were
requested and revealed normal findings; hence she was referred in this institution for
further evaluation and management.
Past Psychiatric Illness:
No history of previous consultation or admission for any psychiatric illness
Past Non- Psychiatric Illness:
No history of Bronchial Asthma, Thyroid problems, Cancer, Hypertension,
Diabetes, Seizure, or any Head Trauma.
Family History:
No history of any psychiatric illness in the family. Hypertension was reported in
the paternal side. No history of Bronchial Asthma, Thyroid problems, Cancer, Diabetes,
Seizure, or any Head Trauma.

Personal History
Infancy:
The patient was an unplanned but wanted pregnancy. She was the sixth
child in a brood of 8. She was delivered at home via NSVD with an aid of hilot.
There were no noted unusualities immediately after birth and first 28 days of life.
She was on exclusive breastfeeding for 6 months and on mixed supplemental
feeding thereafter.
Preschool/childhood:
The patient was average academically. She had always been shy and silent
in class. She had few friends. Although she claimed to be close to his entire
family, she prefers to be alone most of the time.
Adolescence/Adulthood:
The patient was average academically. She was still shy and silent, thus
had few friends. She rarely engaged to any extracurricular activities in school
such as sociocultural or sports festivities. During free time, the patient prefers to
be alone rather than to be with her family and friends. Due to financial
constraints, she was only able to finished high school.
Vocational:
The patient was able to work as a guest relation officer (G.R.O) in a
certain club for 4 years. Currently, she is working as waitress in a local restaurant.
Sexual history:
The patient is heterosexual. She claimed that she was raped when she was
16 years old. For the past several years, she was engaged into more than 10
relationships. She also confessed that she had engaged with multiple sexual
contacts in the past. Her previous partners broke up with her because of his past
experiences. At present, she is living with a live-in partner for 3 years of whom
she had two children. She had another child from a previous partner.

Drug/Substance History:
The patient had a positive history of alcoholism, smoking and illicit drug
use specifically marijuana and shabu. At the age of 19 years old, smoke and drink
alcohol. She could consume at least 3 sticks a day and at least a bottle of beer
daily.
REVIEW OF SYSTEMS
General: No history of body weakness, insomnia or chills.
Skin: No history of rashes, itching, and other skin lesions.
Endocrine System: No history of heat and cold intolerance.
Eye: No complaints of eye itching, redness, swelling, blurring of vision and
excessive lacrimation.
Ear: No history of tinnitus and eye discharge.
Nose: No history of anosmia, epistaxis, nasal discharge, and postnasal drip.
Mouth: No history of bleeding gums, sores, and fissures.
Throat: No history of sore throat.
Neck: No stiffness and limitation of motion.
Gastrointestinal: No history of dysphagia, diarrhea, constipation, hematochezia,
and melena.
Pulmonary: No history of cough, dyspnea, sputum production, asthma, and
hemoptysis.
Cardiac: No history of chest pain, orthopnea, palpitations, and other previous
heart disease.
Vascular: No history of phlebitis, varicosities, and claudication.
Genito-urinary: No history of flank pain, urinary incontinence, discharge.
Neurologic System: No history of seizure, head trauma, and loss of
consciousness.
Hematopoietic: No history of anemia, easy bruising, and signs of bleeding.
Musculoskeletal System: No history of limitation of movement, myalgia, muscle
cramps, joint deformities and swelling.

PHYSICAL EXAMINATION
General Appearance: The patient is awake, conscious, afebrile and not in
respiratory distress
Vital Signs:

BP: 120/80 mmHg


CR: 86 bpm
RR: 18 cpm
T: 36.8C
Height: 155 cm
Weight: 54 kgs

Skin: Brown in complexion. Warm to touch and with good skin turgor. No
suspicious skin lesions.
Head: Normocephalic with no masses and other lesions noted.
Eyes: Anicteric sclera and pink palpebral conjunctivae noted. Pupils are equally
round and reactive to light and accommodation. No discharge.
Ears: Symmetrical; auricles are mobile, non-erythematous, and nontender. No ear
discharge.
Nose: Nasal septum is intact and is at midline. No alar flaring, discharge, and
tenderness.
Mouth and Throat: Lips and oral mucosa are pink and moist. Tonsils are not
enlarged, non hyperemic, and without exudates.
Neck: Trachea is in midline. There are nonpalpable cervical lymph nodes. No
neck vein engorgement. Full neck movement noted.
Chest:
I: Equal chest expansion; No chest deformities
Pa: Nontender; Equal tactile fremitus
Pe: Resonant
A: Clear breath sounds; Equal breath sounds; Equal vocal fremitus
Cardiovascular:
I: Adynamic precordium

Pa: No heaves and thrills


A: Distinct heart sounds; Regular cardiac rate and rhythm; PMI heard at
5th ICS left MCL; No murmurs
Breast:
Not assessed
Abdomen:
I: Protuberant; no scars and lesions noted
A: Normoactive bowel sounds
Pe: Tympanitic
Pa: Soft and nontender. No hepatosplenomegaly
Anus, Rectum, Genitals:
Not assessed
Extremities: Full pulses noted; CRT < 2 seconds; No edema and cyanosis
Musculoskeletal: No limitation of movement, joint swelling and deformity.
Muscle strength of 5/5 on all extremities
Consciousness Level: Awake, conscious, and responsive
Neurologic:
E4 V5 M6 (GCS 15)
Cranial Nerves:
II: Pupil equally round and reactive to light and accommodation; 2
mm in size
III, IV, VI: Intact extraocular movements, (-) nystagmus
V: Intact facial sensation; (+) corneal reflex
VII: No facial asymmetry
VIII: Able to hear normal voice tones
IX, X: No difficulty in swallowing; (+) gag reflex
XI: No shoulder lag
XII: Tongue is at midline, (-) atrophy and fasciculations, (-)
slurring of speech
Muscle Strength Grade: 5/5 on all four extremities
Sensation: 100%

MENTAL STATUS EXAMINATION:


I.

Presentation
General appearance: Unkempt. Foul smelling. Wearing a white

II.

III.

IV.
V.
VI.

VII.

VIII.

shirt, shorts and malong. Barefooted.


Behavior and Psychomotor Activity: (+) Withdrawn, (+)

Restlessness and (+) Agitation


Doctor- patient interaction: Uncooperative
Mood and Affect
Mood: (+) Anxious, (+) Frightened
Affect: Blunted
Neurovegetative Dysfunction
Sleep: Mixed insomnia
Appetite: Decreased
Diurnal Variation: None
Libido: Decreased
Attention span: Poor
Speech: Loud, Mumbled
Perception: (+) Auditory hallucination Gi-ingnan ko sa Ginoo na magbinutan. Denies visual hallucinations
Thought Process: Intact
(+) Looseness of association
(+) Tangentiality
(-) Neologism
(-) Flight of Ideas
(-) Circumstantiality
(-) Thought blocking
Thought Content

(+) Delusion: Religious Delusions Gisugo ko sa Ginoo

(-) Precoccupation

(-) Suicidal Ideation

(-) Homicidal ideation

(-) Ideas of reference

Sensorium and Cognition

Orientation: Oriented to person but not to place and time

Memory: Uncooperative

Concentration and attention:

o Serial subtraction: Uncooperative and incomprehensible


answers
o Spelling: Uncooperative and incomprehensible answers
o Abstract thought: Uncooperative and incomprehensible
answers
o Information and Intelligence: Uncooperative and
incomprehensible answers
IX.

Judgement and Insight

Judgement: Impaired

Insight: Level I

SALIENT FEATURES

27 years old
Female
High school graduate
Chief complaint: Change in behavior
Three weeks postpartum
Silent and shy type
Prefers to be alone
Talks to oneself
Decreased appetite
Few friends
(+) History of smoking, alcohol and illicit drug use
Worked as a G.R.O.
Poor hygiene
Withdrawn
Frightened
Anxious
Blunted affect
Mixed Insomnia
Decreased appetite
Loud, mumbled speech
(+) Auditory Hallucination
(+) Religious Delusion
Disoriented to Time and Place

Uncooperative and incomprehensible answers to questions related to

memory, concentration and attention


Impaired Judgement
Insight Level 1

Admitting Impression: BRIEF PSYCHOTIC DISORDER, POSTPARTUM ONSET


DIFFERENTIAL DIAGNOSIS
Differential
diagnosis
Schizophreniform
disorder

DSM V Criteria
A. Two (or more) of the following, each
present for a significant portion of
time during a 1-month period (or less
if successfully treated). At least one of
these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech
4. Grossly disorganized or catatonic
behavior.
5. Negative symptoms
B. An episode of the disorder lasts at
least 1 month but less than 6 months.
When the diagnosis must be made
without waiting for recovery, it should
be qualified as provisional.
C. Schizoaffective disorder and
depressive or bipolar disorder with
psychotic features have
been ruled out because either 1 ) no
major depressive or manic episodes
have occurred concurrently with the
active-phase symptoms, or 2) if mood
episodes have occurred during activephase symptoms, they have been
present for a minority of the total
duration of the active and residual
periods of the illness.

R.A.
Rule In:
(+) Auditory
hallucinations
Gi-ingnan ko sa
Ginoo na
magbinut-an.
(+) Religious
Delusions
Gisugo ko sa
Ginoo
(+) Grossly
disorganized
behavior
(Withdrawn
behavior)
(+) Negative
symptoms:
Blunted affect,
Neglect of
personal hygiene
and Social
Withdrawal.
Disorganized
Speech: Loud and
Mumbled
Rule Out:
The episode of the
disorder lasted
less than 1 month
Disturbance is not

D. The disturbance is not attributable to


the physiological effects of a
substance or another medical
condition.
Specify if:
With good prognostic features:
This specifier requires the presence of at
least two of the following features: onset
of prominent psychotic symptoms within
4 weeks of the first noticeable change in
usual behavior or functioning; confusion
or perplexity; good premorbid social and
occupational functioning; and absence of
blunted or flat affect.

attributable to
psychological
effects of
substance.
No major
depressive or
manic episodes

Without good prognostic features:


This specifier is applied if two or more of
the above features have not been present.
Schizophrenia

Rule In:
A. Two (or more) of the following, each
(+)
present for a significant portion of
Auditory
time during a1 -month period (or
hallucinations
less if successfully treated). At least
Gi-ingnan ko sa
one of these must be (1 ), (2), or (3):
Ginoo na
1. Delusions.
magbinut-an.
2. Hallucinations.

(+)
3. Disorganized speech (e.g.,
Religious
frequent derailment or
Delusions
incoherence).
Gisugo ko sa
4. Grossly disorganized or catatonic
Ginoo
behavior.

(+)
5. Negative symptoms (i.e.,
Grossly
diminished emotional expression
disorganized
or avolition).
behavior
(Withdrawn
B. For a significant portion of the
behavior)
time since the onset of the

(+)
disturbance, level of functioning
Negative
in one or more major areas, such
symptoms:
as work, interpersonal relations,
Blunted affect,
or self-care, is markedly below
Neglect of
the level achieved prior to the
personal hygiene
onset (or when the onset is in
and Social

childhood or adolescence, there is


failure to achieve expected level

of interpersonal, academic,
or occupational functioning).
C. Continuous signs of the
disturbance persist for at least 6
months. This 6-month period
must include at least 1 month of
symptoms (or less if successfully
treated) that meet Criterion A
(i.e., active-phase symptoms) and
may include periods of prodromal
or residual symptoms. During
these prodromal or residual
periods, the signs of the
disturbance may be manifested by
only negative symptoms or by
two or more symptoms listed in
Criterion A present in an
attenuated form (e.g., odd beliefs,
unusual perceptual experiences).
D. Schizoaffective disorder and
depressive or bipolar disorder
with psychotic features
have been ruled out because
either 1 ) no major depressive or
manic episodes have
occurred concurrently with the
active-phase symptoms, or 2) if
mood episodes have
occurred during active-phase
symptoms, they have been
present for a minority of the
total duration of the active and
residual periods of the illness.
E. The disturbance is not attributable
to the physiological effects of a
substance (e.g., a
drug of abuse, a medication) or
another medical condition.
F. If there is a history of autism

Withdrawal.
Disorganiz
ed Speech: Loud
and Mumbled

Rule Out:

The
episode of the
disorder lasted
less than 1 month

Disturbanc
e is not
attributable to
psychological
effects of
substance.

No major
depressive or
manic episodes

No history
of autism
spectrum disorder
or communication
disorder of
childhood onset

spectrum disorder or a
communication disorder of
childhood onset, the additional
diagnosis of schizophrenia is
made only if prominent delusions
or hallucinations, in addition to
the other required symptoms of
schizophrenia,
are also present for at least 1
month (or less if successfully
treated).
Brief psychotic
disorder

.
A. Presence of one (or more) of the
following symptoms. At least one of
these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent
derailment or incoherence).
4. Grossly disorganized or catatonic
behavior.
Note: Do not include a symptom if it is a
culturally sanctioned response.
B. Duration of an episode of the
disturbance is at least 1 day but less
than 1 month, with
eventual full return to premorbid
level of functioning.
C. The disturbance is not better
explained by major depressive or
bipolar disorder with
psychotic features or another
psychotic disorder such as
schizophrenia or catatonia,
and is not attributable to the
physiological effects of a substance
(e.g., a drug of abuse,
a medication) or another medical
condition.
Specify if:

Rule In:

(+)
Auditory
hallucinations
Gi-ingnan ko sa
Ginoo na
magbinut-an.

(+)
Religious
Delusions
Gisugo ko sa
Ginoo

(+)
Grossly
disorganized
behavior
(Withdrawn
behavior)

(+)
Negative
symptoms:
Blunted affect,
Neglect of
personal hygiene
and Social
Withdrawal.

Disorganiz
ed Speech: Loud
and Mumbled

(+) Level
of functioning in
one or more major
areas, such as
work and
interpersonal

With marked stressor(s) (brief


reactive psychosis): If symptoms occur in
response to events that, singly or
together, would be markedly stressful to
almost anyone in similar circumstances

in the individuals culture.


Without marked stressor(s): If
symptoms do not occur in response to
events that, singly or together, would be
markedly stressful to almost anyone in
similar circumstances in the individuals
culture.
With postpartum onset: If onset is
during pregnancy or within 4 weeks
postpartum.

relationship
markedly below
the level achieved
prior to the onset
Duration
of the episode is
less than a month
with eventual full
return to
premorbid level of
functioning
Disturbance is not
attributable to
psychological
effects of
substance.
No major
depressive or
manic episodes

Final Diagnosis: BRIEF PSYCHOTIC DISORDER, POSTPARTUM ONSET

Course in the Ward:


First Hospital Day
The patient was admitted in the Crisis Intervention Unit. Vital signs were
monitored and recorded every 4 hours. She was placed on diet as tolerated (DAT). Upon
admission, the following laboratory work-ups were requested: complete blood count,
serum sodium and potassium, and urinalysis. Her medications consisted of Clozapine 10
mg/ODT PO single dose, Haloperidol 5mg/tab 1 tab HS, Biperiden 2 mg/tab 1 tab BID
PRN for EPS and Clonazepam 2 mg/tab tab PO PRN for agitation and insomnia.
Patient was also placed under suicide, homicida and escape precautions.
In the evening, the patient was noted to be agitated, hence given Levomeprazine
100 mg/tab tablet.
Second Hospital Day
The patient was fairly groomed and dressed. She had displayed appropriate
behavior. She was cooperative. She had a euthymic mood with appropriate affect. She
reported that she wasnt able to sleep well and had poor appetite. She had a good
attention and spontaneous speech. Patient had auditory hallucinations in which she
claimed that Ge-ingnan ko sa Ginoo na magbinut-an. She had religious delusion of
which she claimed that Gi-sugo ko sa Diyos. She was oriented to person, time and
place. She was able to do serial subtractions and spelling (W-O-R-L-D/D-L-R-O-W). She
had a good fund of knowledge and had a concrete abstract thought. Lastly, she had an
unimpaired judgment and insight level was VI.
DISCUSSION
Brief Psychotic Disorder is a recurrent, transient thought disorder, which
typically occurs in adolescence or young adulthood. (DSM-V). The disorder is two times
more likely to occur in women and is most commonly seen in adolescents and young
adults in their 20's and 30's. This is consistent with R.A.s case who is a 27 years old
female.

It is of short duration, although it can result in increased risk of suicide, or


inability to perform self-care (American Psychiatric Association, 2013). This disorder
will manifest over a period of about two weeks or less, resolve in less than one month,
and the person will return to their pre-morbid level of functioning prior to the psychotic
state. `The disorder is typically a response to an extreme stressor, such as combat or a
series of stressors, which overwhelm the individual's coping skills and it tends to resolve
within one month, and the individual typically returns to their former level of
functioning.
Brief psychotic disorder can also occur in conjunction with Borderline Personality
Disorder or Paranoid Personality Disorder.
Symptoms
Brief Psychotic Disorder is a thought disorder in which a person will experience
short term, gross deficits in reality testing, manifested with at least one of the following
symptoms:
1

Delusions - strange beliefs and ideas which are resistant to rational/logical dispute
or contradiction from others. This is evident in R.A.s case of whom she claimed
to be a messenger of God.

Hallucinations - auditory, or visual. This is also evident in the patient presented


of whom she claimed that God is telling him to be good.

Disorganized Speech - incoherence, or irrational content. In this case, patient had


a loud and mumbled speech. Upon interview, she displayed looseness of
association and tangentiality.

Disorganized or Catatonic Behavior - repetitive, senseless movements, or


adopting a pose which may be maintained for hours. The individual may be
resistant to efforts to move them into a different posture, or will assume a new
posture they are placed in. Restless and agitation was noted during interview.

Diagnosis
To fulfill the diagnostic criteria for brief psychotic disorder symptoms must
persist for at least one day, but resolve in less than one month. The psychotic episode

cannot be attributed to substance use (ethanol withdrawal, cocaine abuse) or a medical


condition (fever and delirium), and, the person does not fit the diagnostic criteria for
Major Depressive disorder with psychotic features, Bipolar disorder with psychotic
features, or Schizophrenia.
The patients symptoms have been present 8 days prior to admission and had no
resolution.
To further describe the disorder, five specifiers can be used. This includes the
following:

With marked stressors.

The psychotic episode appears following an acute

stressor, or series of stressors, which would overtax the coping skills of most

individuals.
Without marked stressors. There is no apparent stressor preceding the psychotic

episode.
Post-partum. This disorder can appear during pregnancy or within one month
following childbirth. Three weeks prior to admission, patient delivered a live term
baby with no postnatal illness noted.

With catatonia.
Severity. The clinician can rate the severity of the psychotic episode during the
last seven days using a five point scale- Zero ( Absent ) to Four ( Present and
severe)

Risk Factors and Risk Markers


Brief psychotic disorder can precipitated by stressors which overwhelm the
individual's coping skills. This includes the following: acute or chronic stress,
underdeveloped coping skills, isolation, and lack of social supports, individuals in
environments such as combat or domestic violence, trauma and personality Disorder.
The patient was able to work as a G.R.O. which could be a possible source of her
psychological and social stressors. Although she mentioned that she is currently working
as a waitress, there is insufficient information that she had quitted from her previous
work. Alcohol, cigarette and drug intake is an ineffective way of coping with her current
condition. Precise assumption cant be made with regards to social support given by her

family. It had already been established that she had only few friends in the past and no
close friends at present.
Treatment
In treating Brief Psychotic Disorder, the patient was admitted for crisis evaluation
and stabilization with the aid anti-psychotic medications. She was admitted in the Crisis
Intervention Unit. CBT (Cognitive Behavioral therapy) may be useful for her to learn
coping and stress reduction. The patient responded well with anti-psychotics with
dramatic improvement in the second hospital day, thus might require her to stay at CIU
for only few days.